<ul class="main-two-cols">
	<li class="two-cols-left">
		<h2 class="singlerow">USER DETAILS</h2>
		<ul class="rows">
			<li class="leftcol">Name</li>
			<li class="rightcol">
				<input type="text" name="name" id="name" value="<?=$details_row['name']?>">
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">Supervising Doctor</li>
			<li class="rightcol">
				<select name="supervisor_id" id="supervisor_id">
					<option value=""></option>
				</select>
			</li>
		</ul>
		<br clear="all"/>

		<h2 class="singlerow">Medicare Australia Childhood Immunisations (ACIR)</h2>
		<ul class="rows">
			<li class="leftcol">Ancillary Provider No.</li>
			<li class="rightcol">
				<input type="text" name="ancillary_provider" id="ancillary_provider" value="<?=$details_row['ancillary_provider']?>">
			</li>
		</ul>

		<br clear="all"/>

		<h2 class="singlerow">HEALTHCARE IDENTIFIER</h2>
		<ul class="rows">
			<li class="leftcol">HPI-I No.</li>
			<li class="rightcol">
				<input type="text" name="hpi_i_no" id="hpi_i_no" value="<?=$details_row['hpi_i_no']?>">
			</li>
		</ul>
	</li>

	<li class="two-cols-right">
		<h2 class="singlerow">PCEHR DETAILS</h2>
		<ul class="rows">
			<li class="leftcol">Title</li>
			<li class="rightcol">
				<input type="text" name="pcehr_title" id="pcehr_title" value="<?=$details_row['pcehr_title']?>">
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">First Name</li>
			<li class="rightcol">
				<input type="text" name="pcehr_fname" id="pcehr_fname" value="<?=$details_row['pcehr_fname']?>">
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">Middle Name</li>
			<li class="rightcol">
				<input type="text" name="pcehr_mname" id="pcehr_mname" value="<?=$details_row['pcehr_mname']?>">
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">Last Name</li>
			<li class="rightcol">
				<input type="text" name="pcehr_lname" id="pcehr_lname" value="<?=$details_row['pcehr_lname']?>">
			</li>
		</ul>
		<br clear="all" />
		<input type="checkbox" name="auto_capitalize" id="auto_capitalize" value="1" <?=($details_row['auto_capitalize'] == 1)?'checked':''?>> Auto capitalize names
	</li>
</ul>